Tomorrow's health systems: from event-driven healthcare to wellness through the life course

Professor Richard Barker

Today’s healthcare is mostly sought and delivered around health events: the appearance of symptoms. Professionals respond but often the disease has gone beyond the point at which its reversal is simple, and care very cost-effective. 

Tomorrow’s healthcare must be geared in much larger measure to transitions between the main stages in life: conception, birth, childhood, adolescence, adulthood, middle age, the elderly years and the end of life.

Tomorrow’s health consumer will want to manage their health life in a much more anticipatory way, drawing on knowledge about themselves (from their disease predisposition to their preferences about how to exercise) that will be stored in an accessible digital form and integrated into the rest of their life. 

The smallest changes will be in the earliest years. We already seek to prevent problems via prenatal care, support for childbirth and vaccination against common diseases. The greatest changes may be enabled by genomics. Testing both the parents and the DNA of the fetus (circulating in the mother’s bloodstream) will provide clues to either defined inherited diseases or predispositions that have lifelong consequences, in terms of diet, screening or protection from harmful exposures.

The goal throughout—starting in the earliest years—is to anticipate disease, detect it as early as possible, ideally reverse its onset, and if not, to manage it proactively and avoid the complications that often occur with it.

Diabetes is a classic example. We will increasingly identify the genetic profile that predisposes to the disease. We must, however, learn to regard that genetic profile as a challenge to health life management, not a ‘sentence’ meted out by the combination of parental genes we inherit. As we modify diet and maintain fitness and wellness to minimize the risk of diabetes, we will find that our epigenomics—the chemical modification of our genes that controls their expression—will respond. That can begin in childhood: indeed, it must do so if we are to avoid the ‘epidemic’ of childhood obesity and subsequent type 2 diabetes that we are now seeing.

Even if we are unsuccessful in fully controlling these early years, we will be able to pick up pre-diabetes with a simple panel of tests. There is strong evidence that taking the right action to restore cardiovascular health will reverse the early stages of the disease. 

Adolescence brings a host of hormonally mediated challenges, and also temptations to begin smoking, drinking and taking drugs. Recent data show that smoking and drinking can cause subclinical arterial stiffness even in teenagers. For too long we have assumed that all we need to do is to alert youngsters to the challenges and consequences and their good sense will prevail. It works only for a minority. We need to shrewdly use electronic tools to change their paradigms for success as teenagers. Short-term consequences will have much more leverage than long-term health. We must define wellness in teenagers’ terms, and make it cool.  

A few years on, and a half—or nearly half—of the population encounter another transition: to motherhood. It is a stage in life in which women are more open to health messages than perhaps any other. Of course, we must take advantage of tools to maximize the health of the child, but – as well as the conventional test for HIV – we can take the opportunity (with appropriate consent) to take stock of the mother’s health also, across a broad front. 

Middle age is a pretty slippery concept these days. Some seem to hit it at 45, some 65, some even later. But for too many people it gets defined as the appearance of symptoms of chronic disease, and it is said that by 65 most people have at least 3 chronic conditions. Of all the things in the life course we much change, this is highest on the list.

To do so, we must probe much earlier and encourage people to measure their cardiovascular, pulmonary and immunological health through the adult years. These profiles will contain – but go far beyond – measuring blood pressure, cholesterol, FEV, etc. We will have the ability, perhaps with just a simple drop of blood, to measure biological wellness alongside the parameters of physical wellness that the smart-phones, watches or implantable chips will already report on.

Our wellness profile should also include mental health. Mens sana in corpore sanem, and all that. Collecting that data from our use of electronic media will also be quite straightforward. 

The result is a threefold profile—physical, biomedical and mental—that should monitor and guide us through the adult years. Specific tests for cancer, early heart disease, autoimmune and lung conditions will play their part, but the goal will be to avoid or delay the diseases that we can test for.

The transition from middle age to becoming ‘elderly’ is also becoming quite difficult to define, as ceasing daily work or strong physical activity is just one measure. For some it will continue to happen in the 60s; others may be octogenarians before they are ‘elderly’. But the risk of cancer and the consequences of infection are clearly mounting at this point, and again frequent profiling (including detection of any circulating cancer cells combined with very sensitive imaging) will avoid late-stage diseases turning up in the doctor’s surgery.

This change in our mindset is profound. We will no longer wait for the appearance of symptoms before seeking help: we will accept the challenge of managing our own health lives as soon as we start to take responsibility in other areas of life. But we will need support— especially in digital form, the subject of my next insight.